Medicaid Fraud Control Unit

ABOUT THE UNIT

The State of Delaware and the Federal Government have designated the Medicaid Fraud Control Unit (MFCU) to investigate and prosecute illegal acts relating to Medicaid funds. Created in 1980, the MFCU, which is housed within the Delaware Department of Justice, is designed to protect the Delaware residents who receive Medicaid and the taxpayers who support the program. The MFCU has a professional staff of prosecutors, investigators and auditors who review allegations involving:

Medicaid Fraud: Civil or Criminal Fraud against the state by healthcare providers who treat Medicaid recipients.

WHAT IS MEDICAID?

Medicaid is a federal/state cost-sharing program that provides healthcare to people who are unable to pay for such care. The Delaware Medicaid program is administered by the Delaware Department of Health and Social Services.

The MFCU does not investigate fraud committed by Medicaid recipients; such cases should be referred to the Welfare Fraud Unit (Audit recovery management systems) within the Department of Justice.

WHAT IS MEDICAID PROVIDER FRAUD?

Medicaid providers include doctors, dentists, hospitals, nursing homes, clinics, pharmacies, ambulance companies and anyone else who is paid by Medicaid for a healthcare service. Fraud by a Medicaid provider is usually evidenced by one or more of the following:

UPCODING - when healthcare providers bill Medicaid for a more expensive treatment or service than the one they actually provided to the patient; or by filling a prescription with a generic drug, while billing for the more expensive name brand version of the medication;

PHANTOM BILLING - billing for goods or services not provided, such as billing for patient visits that never took place or for blood tests when no samples were taken;

UNNECESSARY SERVICES - billing for unnecessary services can include billing for items that patients do not need at all, such as oxygen concentrators, hospital beds or wheelchairs;

DOUBLE BILLING - billing Medicaid twice for the same procedure, sometimes by submitting a bill at the beginning of the month and a second bill at the end for the same service;

UNBUNDLING - submitting bills for individual procedures as if the service were performed on different days for procedures that the doctor performed during one day as part of one operation;

KICKBACKS - when medical suppliers, home health agencies, etc., give things of value to other health care providers in exchange for patient referrals.

Acts like those described above may violate state and federal laws and subject the guilty provider to imprisonment, significant fines and exclusion from the Medicaid program.

HOW DOES MEDICAID FRAUD AFFECT ME?

Medicaid fraud affects everyone. When providers steal from Medicaid, they decrease the resources available to the program. Residents living near the poverty level, who would have been qualified for the program, might be excluded because of a lack of resources. Medicaid fraud also reduces the quality of treatment as dishonest providers try to reduce costs and increase personal profit. To compensate for the fraud, the state must either decrease services in other areas or raise taxes.

HOW CAN I SPOT MEDICAID FRAUD?

Many of the cases prosecuted by the MFCU start with information from the public. Here are several hints to help detect possible fraud:

if a provider suggests treatment or services that you do not realistically believe are necessary, be cautious of the recommendation;

if you receive Medicaid and are in a healthcare facility, check your personal funds account regularly;

if you are visiting in a healthcare facility, pay attention to the patient's appearance and the appearance of the room and the facility or any other indication of neglect.

HOW CAN I REPORT MEDICAID FRAUD?

You can anonymously report Medicaid Fraud by calling the Department of Justice Healthcare Provider Fraud Hotline at (302) 577-5000.